‘Ask Me Anything’

The students shared their recommendations for public health professionals and others interested in starting similar outreach initiatives in a commentary, “‘Ask Me Anything’: Lessons learned in implementing a COVID-19 vaccine information initiative in Massachusetts jails,” published in Vaccine in April.

In autumn 2021, the students returned to the jails to hold additional information sessions on vaccine boosters and, for individuals who had not attended previous sessions or had not yet decided to get vaccinated, to answer general questions about the vaccines.

Harvard Medicine News spoke with Katherine Rich, a third-year HMS Pathways student, about the initiative and the students’ work and experiences.

HMNews: What was the impetus for you to get involved in this project?

Rich: A lot of people in the beginning of the pandemic said COVID was a great equalizer. But it really wasn’t. Very quickly, it became apparent that COVID-19 actually was laying bare and exacerbating many deep inequities.

We knew that COVID-19 had the potential to be disastrous within jails and prisons, and unfortunately, we saw many examples of uncontrolled spread and disproportionate cases within these settings, with not a lot of transparency around the health care being provided.

I — and I think I speak for the group too — had a desire to help combat these disparities and try, even if in a small way, to help reduce the risk of COVID in these settings.

Massachusetts prioritized individuals in congregate living settings, including jails and prisons, during phase 1 of vaccine rollouts. Despite this, vaccine uptake in jails was low. Our specific initiative of going in and talking to people was really sparked by the need to provide more information about the vaccines to individuals who didn’t have much access to outside information, especially from trusted members of the community or the health care community.

On a personal note, I’ve been passionate about carceral health care for a while, beginning with work and research I did prior to medical school in New Haven. My work continued during medical school, before COVID-19, through volunteering at Boston’s Nashua Street Jail with the Crimson Care Collaborative.

In fact, one of my memories of our last education session at the Nashua Street Jail in March 2020, before COVID really shut down any volunteer work, was talking about COVID to some individuals in a housing unit, and someone saying to me as we wrapped up, "But how will we know if we're getting the correct information?”

The person added, they're going to forget about us.

That really stuck with me.

HMNews: Who were some of the key community members you worked with?

Rich: Dr. Alysse Wurcel, a professor of medicine at Tufts who does a lot of work in the county jails in Massachusetts started the initiative and was key to this all coming together. Other important partners were community faith leaders Dr. Gloria White-Hammond and Reverend Liz Walker. Many of these individuals were also really crucial at the state level in advocating that individuals who were detained should be prioritized in [vaccination] phase one.

They realized there was a pretty great, unmet need to provide information about the vaccines, and about COVID, to individuals. And that it would be helpful if people not affiliated with the jail started doing this.

HMNews: So what were your hopes and goals for the meetings between clinicians, faith leaders, students, and the individuals in the jails?

Rich: That we could, if not overcome, at least address some of the hesitancy and mistrust people had about the vaccines. Particularly during our initial sessions in the spring, a lot of individuals we talked to were nervous, and they asked questions like am I a guinea pig, and why do we get access to the vaccine first.

Unfortunately, there is a history of experimentation without consent within prisons and jails. It was so important to go in with different voices. The hope really was to give people the power of fully informed decision-making.

Being able to go in as an outsider, and talk and lean into those tough conversations about racism, talk about the vaccine approval process, what we knew — and didn’t know yet — about the science and then say, But we're not here to make you take it. We're really here just to give you some information because you deserve to have correct information to help make your own decision.

We let them know there were vaccination signups available but told them that in no way were we going to twist an arm to get [them] to sign up.

That was really our first intention. Our second intention was to hopefully drive up rates of vaccination. And we were up front about the higher risk of COVID in jails. But the first and foremost goal was to provide increased access to correct information.

HMNews: You've talked about the role of medical distrust. How were students and clinical leaders received by the incarcerated individuals and how did the conversations go?

Rich: The primary strength of our program was really this mix of individuals who were coming in, from the faith leaders who had long-existing ties to the community, to the clinical leaders and infectious disease doctors, to individuals that reflected large swaths of the community because we were intentional about recruiting [student and faculty] volunteers from diverse backgrounds. We also always tried to bring someone who spoke Spanish to each session.

I think all this did help increase trust. It's easier [for incarcerated individuals] to engage with people who are not affiliated with the jail.

We had about a five-minute spiel that we would start every session with, and then we’d break into a more free-flowing question and answers session.

We’d introduce ourselves and say that we were not being paid by the jail. We would state right out front that there might be a lot of reasons to distrust the vaccine, particularly by someone who was incarcerated.

We often used explicit terminology like, look, we understand that there’s a long history of medical abuse, and sometimes we’d acknowledge that a lot of randomized controlled trials have been done on incarcerated individuals without consent.

We talked about racism and distrust within the community, why individuals would be hesitant to accept any medical intervention from the jail due to past personal and/or community experiences or just the heavy history that they carried with them.

I think being up front about these dynamics did open conversations and allowed people to say OK, you're not here just to tell me I have to take the vaccine; you're really here to have an honest frank conversation.

And then we'd answer questions about anything from does this cause infertility, to I heard that there are magnets being put in my arm — is that true?

We opened the conversations with, ask anything. Nothing is silly as long as we're being respectful. And we'll tell you when we don't know and we'll tell you what we do know.

And we acknowledged that this was a big decision, to figure out what to put in your body. But also, we told them being in jail increases your risk of [getting] COVID. And we explained that this is what we've seen with COVID [in hospitals and clinics] and why we're scared, and why we're motivated to be here. We talked about misinformation, and tried to address some of the myths.

We shared the fact that we'd been vaccinated, which I think was helpful.

And there were definitely times that we entered units and people would ask us why we were there and saying that people coming into the jail is going to increase the risk of COVID and if everyone stayed out, we wouldn't have COVID.

Being able to lean into those tougher conversations or comments did help us build trust. We definitely learned a lot of lessons this way. So we were never by any means perfect, but we reflected along the way. We did have many people sign up for vaccination after our sessions — over a thousand in total.

HMNews: And how were you received by the facility personnel?

Rich: Dr. Wurcel’s preexisting relationship with the Massachusetts Sheriffs Association and the county jails in Massachusetts was the only way that we were able to conduct these sessions, and really emphasized to me the importance of building community and multipartner relationships. And importantly, having these relationships before a crisis hits.

During every session, a staff member of the jail was with us, and we were up front with what we were trying to do. Facilities and staff were often, I think, grateful for the sessions. Certainly many were motivated and really wanted to make sure people were vaccinated. We pitched ourselves as collaborators and partners, knowing that the system is understaffed and overworked as well.

HMNews: So, what are you recommending about these vaccine education initiatives and how they could be implemented and sustained at a broader scale?

Rich: It was a great opportunity, and I think we figured out some lessons that could be applied nationally, or at least in other areas. In our article we included details of how information sessions could best be done, including the strong recommendation to host sessions within housing units versus hosting sessions outside of units where individuals would have to sign up and then travel to. Hopefully those lessons are helpful for individuals thinking about running a session.

Perhaps the most important lesson is that these sessions are best as collaborative efforts. It shouldn’t just be a group of three doctors, or a group of three students, or a group of three faith leaders. When you have a mix of individuals, that's powerful. When those types of groups are possible, you can so much more easily begin to build relationships of trust, both from a facility level and from the audience level.

In terms of sustainability, that's something we've struggled with. It was student-run, it was volunteer. Luckily at HMS, there’s a large community of individuals who are willing to jump in and help, but a big limitation of the project is that it relied on volunteer efforts and wasn't an institutionalized program.

We reflected on that in the paper. Should this be the role of a public health department? Should there be collaborations like this to not only talk about COVID but to talk about HIV testing, or hep C testing, or diabetes control?

HMNews: How can HMS and other medical schools foster health advocacy and care for vulnerable populations, such as incarcerated individuals, and include it in the MD curriculum?

Rich: There are a lot of different avenues. It’s an important question — one that was crucial before COVID — and COVID has really made it even more evident. Here at HMS, the Racial Justice Coalition has had some incredible student-led efforts, supported by the institution, including the revamping of orientation. There is now a growing recognition that we all, as students and community members, need to learn about the city and the context of the medical system that we interact with. Having more of these mandatory sessions interwoven throughout the four years of the curriculum is definitely an area that could be expanded.

Also important are opportunities to go out and actually see more of Boston to understand that it's not just what exists within the Longwood medical complex. To really understand the history and current disparities happening in Boston — as well as the many different thriving communities in Boston.

Some opportunities, including volunteer efforts, are already available, such as the Crimson Care Collaborative and the Office for Community Centered Medical Education. There are tons of people at HMS who are thinking about how to support community efforts and doing incredible community-driven work. Centering those efforts and making it really easy for students to connect with mentors is helpful. Definitely this project would have been nothing without our mentors.

I think having education on the clinical wards and having top-down efforts, along with the student-led efforts, is important. A dream of mine would be to see greater investment by hospitals and better collaboration between the different systems many patients go between [to receive care]. And to include more opportunities for students to learn about carceral health care through didactics and clinical experiences. If we all had to spend even one week working within a jail, or at a harm reduction program, or a community health care van — the list is really long of different possibilities — that would be powerful.

Other individuals involved in this work included: Eugene Lambert, Leah Rosenberg, and Mira Kautzky from Mass General; Alice Buckham and Alex Vogel from Brigham and Women’s; Monik Jimenez from Harvard Chan School; Daniel Motta-Calderon from Harvard Chan School and Brigham and Women’s; Rubeen Guardado, Christina Kraus,and Emma Smyth from Tufts; and Parsa Erfani, Ayotomiwa Oluwatomini Ojo, Raquel Sofia Sandoval, Jade Connor, Okechi Chimeka Boms, Kristi Hill, Mimi Yen Li, Caroline Lee, Aisha Oshilaja, all HMS/HSDM students or graduates.

Co-authors on the commentary included Parsa Erfani, Raquel Sofia Sandoval, Katherine Rich, Ayotomiwa Ojo, Liz Walker, Gloria White-Hammond, Eugene Lambert, and Alysse Wurcel.

This interview was edited for length and clarity.